By Lisa Keen
The U.S. Supreme Court, in a 6 to 3 decision, upheld the right of the federal government to provide health care insurance subsidies to people with low income in states that have chosen not to participate in the Affordable Care Act by setting up insurance “exchanges.”
The decision, written by Chief Justice John Roberts, is a big political victory for the Obama administration and a big relief for people with low incomes, including many people with HIV. Lambda Legal, Gay & Lesbian Advocates & Defenders, the National Center for Lesbian Rights joined briefs to the court urging it to uphold the subsidies.
The decision, King v. Burwell, upheld a decision from the Fourth Circuit U.S. Court of Appeals that said the federal government’s subsidies to people with low incomes in all 50 states was consistent with the intent Congress had in passing the Affordable Care Act (ACA).
Lambda, Gay & Lesbian Advocates & Defenders, and other LGBT groups filed a brief urging the Supreme Court to uphold the lower court decision. The brief led by Lambda said that withholding the subsidies from people in the states that did not participate in ACA would “lead to an absurd and catastrophic public health result, especially in the context of HIV….”
Justices Anthony Kennedy, Ruth Bader Ginsburg, Stephen Breyer, Sonia Sotomayor, and Elena Kagan joined the Chief Justice in the majority opinion.
Justice Antonin Scalia wrote the dissent, which was joined by Justices Clarence Thomas and Samuel Alito.
President Obama signed the Affordable Care Act into law in 2010 with the aim of providing health care insurance for all citizens. One aspect of the law required states to create health insurance “exchanges” through which citizens could do comparative shopping and find coverage they could afford. If states decided against creating their own exchange, the law provided for the federal government to set up an exchange for citizens in those states.
The ACA also provided for the federal government to provide subsidies for citizens with low incomes through the exchanges. Opponents of the ACA challenged those subsidies, saying the law meant them to be provided only through state-established exchanges, not through federal exchanges. A conflict arose over the law’s stipulation that the subsidy depended in part on whether the “applicable taxpayer” sought insurance through “an Exchange established by the state….” In writing the regulations to implement the ACA, the Internal Revenue Service said the subsidies were available to a taxpayer who enrolled through “an Exchange,” whether it was established by the state or the federal government.
The majority said “State Exchanges and Federal Exchanges are equivalent….”
“If a State chooses not to follow the directive in [the ACA] that it establish an Exchange, the Act tells the Secretary [of Health and Human Services] to establish ‘such Exchange.’ And by using the words ‘such Exchange,’ the Act indicates that State and Federal Exchanges should be the same,” wrote Chief Justice Roberts.
Justice Scalia called that conclusion “absurd” because “The Secretary of Health and Human Services is not a State.”
Scott Schoettes, HIV Project Director for Lambda, called the majority decision “great news,” saying it protects “access for all” to health insurance, “including people living with HIV who are low-income, rural, southern, Black, and were–before the Affordable Care Act – largely uninsured.”
“No one should be put at greater risk to the ravages of HIV simply because they live in one of the 34 states choosing not to set up its own health insurance exchange,” said Schoettes. Lambda noted that, when ACA was enacted in 2010, “only 17 percent of people living with HIV had private health insurance.” Schoettes said that, while Lambda doesn’t have statistics on the change since ACA, “we know that it has increased substantially, because we know that there are lots of people enrolled through the exchanges today that were not previously able to obtain private health insurance.”
The brief noted that the rate of uninsured LGBT adults with low income went down by eight percentage points during the first year of ACA enrollment.